| NPI | 1992505994 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CONSUELO INES SALAZAR Executive Assistant 847-951-1652 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Enumeration Date | 2025-03-18 |
| Last Update Date | 2025-03-18 |